Friday, August 22, 2008

Is there a litmus test for CME?

Dr. Daniel Carlat, author of the Carlat Psychiatry Blog, seems to think there is if I read his latest post correctly. His simple litmus test, commercial support (if an activity is commercially supported it can’t be worthy of accreditation) is his alternative to my statement that each offering should be judged on its own merits. Why a litmus test? There isn’t the manpower, it seems, to evaluate each individual offering:

How can ACCME hope to monitor these programs in all the different specialties of medicine with a staff of 12, most of who are not physicians? There are literally thousands of commercially-sponsored programs per year.

So the ACCME doesn’t have the resources to do its job? Maybe the appropriate response would be to advocate for more resources. A litmus test for CME of guilt by commercial association is unfair because it has a prejudicial effect. The bias inherent in such an approach is revealed in Dr. Carlat’s own statement (italics mine):

Yes, it’s true that lack of industry funding does not guarantee unbiased presentations. However, presence of such funding almost guarantees a lack of balance.

Dr. Carlat’s final paragraph concerning the promotion of complementary and alternative (CAM) medicine is interesting. I had linked to three CAM CME offerings as examples of pervasive bias, conflicts of interest and scientifically unsound content in “Pharma-free” programs. I didn’t elaborate because I thought the examples spoke for themselves. Dr. Carlat countered:

Interestingly, the three activities he cites as “concerning” are programs that would never receive industry funding.

Well, yes, of course. That was my point. Maybe I’m missing something. He went on:

They are all courses on integrative or complementary medicine, offered by UCLA, Yale, and NIH. Each covers the clinical evidence for these treatments using evidence-based teaching, but because these techniques have little commercial potential, doctors are poorly informed about them.

Is he giving these programs a free pass? For excellent discussions on what’s wrong with that type of offering I would point Dr. Carlat to theseresources.

4 comments:

Anonymous
said...

Dear Dr. Donnell, I have enjoyed reading your responses to Daniel Carlat's postings. Thought you might be interested in my occasional blog http://carlatreport.livejournal.com/ It is my belief that he is frequently inconsistent, has many errors in his pronouncements about pharmacology, and also in how he presents himself (as you will note in my blog, he has referred to himself as 'professor', the highest academic rank*, when in fact he is an assistant clinical professor (among the lowest ranks; see his self-description on his blog and Report). This seems an unusual thing to do when he castigates others for not providing full disclosure, and writes a blog whose mastheard refers to supporting a search for honesty.

Cordially, Carl Weisman MD

*See NY Times op-ed piece 'Diagnosis: conflict of interest' by Daniel Carlat, on June 13, 2007.

I was interested to see Carlat critical of Eli Lilly applying to the FDA for new uses (back pain) for it's drug Cymbalta.* Basically, he views new uses for an old drug as purely a financial gambit. Interestingly, when the topic is trazodone, he finds it very appropriate to use this antidepressant for something it has never been systematically tested for (insomnia). Now Lilly has conducted formal studies of Cymbalta for this new use, and formally asked the FDA for review of the data for approval; in contrast, Carlat recommends trazodone without having a body of data to support this use, and without FDA approval. His justification provides no data, saying only "psychiatrists prescribe it off label to treat insomnia, because it works so well."** So, is he in favor of using old drugs in new ways, or is he not? His view on the subject of multiple uses of a drug seems to depend on whether it fits his political agenda or not.

Peer review OR ‘Are you likely to tell the boss that his article is a dog?’

Most medical publications help assure the quality of the material presented by submitting it to ‘peer review’. Editors keep a file of experts in various areas. When a hopeful author submits a scientific paper, it is sent to these experts (typically two or three), who evaluate it and send their recommendation about publishing it to the editor. Their comments are sent to the author, and because they are anonymous, the reviewers are free to speak their minds. (In most journals, incidentally, the author’s name has been removed from the copy of the paper that had been sent to the reviewers.) If the reviewers and editor decide that the paper has merit but could be improved, the author is allowed to respond to the comments, the revised paper is re-evaluated by anonymous reviewers, and if successful, the paper is published.

Obviously this system is far from perfect. It is cumbersome and increases the time it takes to publish an article. But it is a little like a comment that has been made about democracy—that it has many faults and irritations, but it’s far better than any other system of governance which has been devised.

Now here’s the rub. The Carlat Psychiatry Report claims to be peer reviewed. The web site describes the process as follows: ’All articles go through a rigorous peer-review process. First drafts are initially reviewed by Dr. Marcia Zuckerman, our associate editor, and are then sent to our entire Editorial Board for further review and comment. One (sic) the entire board is satisfied with the final content, the article is sent for final proofreading and printing.’ In other words, the chief editor (Dr. Carlat) sends his paper to his editorial board, all of whom know who the author is, and in effect work for him (he is the chief editor), and from whom they presumably receive financial benefit. It is my belief that to call this process ‘peer review’ makes a mockery of the term. in a recent article in Psychiatric Times, Dr. Carlat takes to task a scientist who was both the writer of an article as well as editor of the journal in which it was appeared. Interestingly, this is exactly how the papers in his newsletter are published.

This reproduction of one of my earlier postings summarizes the overall concerns with the Carlat Report and Blog:

As I look back over these postings, the message that comes to me is the power of the Internet. Postings on the web can create impetus for social change. Thomas Friedman, for instance, described how concerted action in the form of blogs and e-mail defeated the plans of a utility company to build 11 coal-fired generating plants with little regard to the environment (New York Times op-ed, March 16, 2007). On the other hand, the web can give a voice to unqualified 'experts' who are quick to express seemingly-authoritative evaluations, but are reticent to admit their lack of qualifications. In the case of the Carlat Psychiatry Report, we have a doctor who has never in his career published a paper on medications in a peer-reviewed journal writing a newsletter that evaluates drugs. We similarly see him earning income from critiizing the ethics of various physicians though he has no special training or expertise in the area. The remarkable thing to me is that his mis-representation of the results of studies are often not noticed by readers, who no doubt are influenced by the belief that if it is on the web, it must have some authority behind it. Interestingly, the Massachusetts Medical Society began an investigation, which Dr. Carlat evaded by cancelling its CME sponsorship of the Report. Free of the restraints imposed by true peer-review process, and that which comes from association with a medical society, he can print whatever he pleases, with little regard for fairness or accuracy. The lesson to me is that the reader's job is to always consider the source when reading materials on the web.